GW1--05729_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I�— t I
�atlnlst r• c l21"cii,\ :14.-WATER7.oNEST, -:Y=rl
Well Contractor Name FROM TO DESCRIPTION
404 3 -A p ft. 31D ft. J$ ,"-
'bp ft. 6Ar ft. I,
NC Well Contractor Certification Number '15:.OU7'ER CASING-110r miilti=cased wells)OR LINER'(if in"ticabler-•' - ' '
`� vt C ' / /h e t FROM TO DIAMETER THICKNESS MATERIAL
A �AJ IJC.[•� ` ft. ft. i in.
Company Name °:16.:INNER CASING OR TUBING. eothermal closed-too ,. ' '
2.Well Construction Permit It: SLa).Q 2— 1 O 2 3 b FROM TO DIAMETER THICxivESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) d ft. I a[ft. ('J . in. c�v,21 elf
3.Well Use(check well use): ft. ft. ln. l
Water Supply Well: ,.17.'SCREEN"•': -' ,; -,`c; .: _.+; . .. .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural cipal/Public ft. it In. .
r Geothermal(Heating/Cooling Supply) esidential Water Supply(single) £t ft. d
Industrial/Commercial Residential Water Supply(shared) 1s:=GROUT %= e
C Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
— - Non-Water Supply Well: - - 4 ft. a� ft. e. t'� ���
Monitoring Recovery f. ft. V�
Injection Well: ft. ft. In.
' Aquifer Recharge Groundwater Remediation
.19:SAND/GRAVEL•PACK(if applicable). :'.: _
Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
(Aquifer Test
Stormwater Drainage ft. it.
ornExperimental Technology 0Subsidence Control ft ft.
jGeothermai(Closed Loop) OTracer '.20DRILLING:LOG(attach additionelsheets.if necessary) '---
FROM TO DESCRIPTION(color.hardness,sot/rock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) co ft. `er ft. d
4.Date Well(s)Completed: ''2t4 L3 Well ID# /Or ft. J8r ft I
1 ft. ft. .
5a.Well Location:�Q vc.14,0Pr-
ft. • ft. .
Taft Y G.ana. 6 Kisi , •
Facility/Owner Name . IA Facility ID#(if applicable) 1t , R• Re l r't Y'",
alb .�I LA. 1"'4J 1 1�G �B�S"a ft. • ft. '� �'L j � 44
•
Physical Address,City,and Zip ft. ft.
Y -;21 REMARKS�� ._.,. ._` SEP e) �� 20.Z3,
Vc �I�'s�.as-c U. 170 20 ZES 3V-7.29 _itift)r►�.a;.��;�pa. -
County Parcel Identification No.(PIN) � r,..—. 4'7•►i 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35`' '{.i'14.6tt/y 7f N Tr 6' ell.av((f2 q W7_
��� r'09q-
6.Is(are)the well(s)'Permanent or Temporary ignat„re of Certified Well Contractor . Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or lallo with 1 SA NCAC 02C.0100 or 1 SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For'Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SI iRMITTAT.TIVC'TRLTCTZONC
56.- 1-
9.Total well depth below land surface: (ft.) -24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100`) construction to the following:
•
10.Static water level below top of easing: Iy C) (ft.) Division of Water R I oiirces,Information Processing Unit, •
• Ifwater level.is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 4.• ., (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (fJabove, also submit one copy of this form within 30 days of completion of well
0.12y construction to the following: t
(i.e.auger,rotary,cable,direct push,etc.) VI
Division of Water Resources,Underground Injection Control.Program,
FOR WATER SUPP Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l r U//�►►
J Method of test: I. A(aci't$'24c.For Water Supply&Injection Wells: In addition to sending the form to
/n►,+� the address(es) above, also submit one copy of this form within 30 days of
1:Y 13b.Disinfection type: 1 lolnk Amount: - completion of well construction th the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016